Female ACNE patients:

Are your menstrual cycles regular?

Yes

No

Is the acne worse with menses?

Yes

No

Regarding moles or growths, any change in the following?

Color

Size

Shape

Texture

Please list any MEDICATIONS you are currently taking. (Include over the counter medications, vitamins, birth control pills, and herbal supplements such as ginseng, ginkgo biloba, Echinacea st john’s wort.)

Do you have any ALLERGIES to medications or foods? (such as penicillin, sulfa, shellfish, peanuts)